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Limited Electronic Distribution Rights This PDF document was made available from www.rand.org as a public service of the RAND Corporation. 6 Jump down to document THE ARTS CHILD POLICY CIVIL JUSTICE EDUCATION ENERGY AND ENVIRONMENT HEALTH AND HEALTH CARE INTERNATIONAL AFFAIRS NATIONAL SECURITY POPULATION AND AGING PUBLIC SAFETY SCIENCE AND TECHNOLOGY SUBSTANCE ABUSE TERRORISM AND HOMELAND SECURITY TRANSPORTATION AND INFRASTRUCTURE WORKFORCE AND WORKPLACE The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. Visit RAND at www.rand.org Explore RAND Health View document details For More Information Purchase this document Browse Books & Publications Make a charitable contribution Support RAND This product is part of the RAND Corporation technical report series. Reports may include research findings on a specific topic that is limited in scope; present discus- sions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research profes- sionals, and supporting documentation; or deliver preliminary findings. All RAND reports undergo rigorous peer review to ensure that they meet high standards for re- search quality and objectivity. Evaluation of the Patient Safety Improvement Corps Experiences of the First Two Groups of Trainees Stephanie S. Teleki, Cheryl L. Damberg, Melony E. Sorbero, Allen Fremont, Lily Bradley, Donna O. Farley Sponsored by the Agency for Healthcare Research and Quality The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R ® is a registered trademark. © Copyright 2006 RAND Corporation All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from RAND. Published 2006 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213 RAND URL: http://www.rand.org/ To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: order@rand.org Library of Congress Cataloging-in-Publication Data Evaluation of the Patient Safety Improvement Corps : experiences of the first two groups of trainees / Stephanie S. Teleki [et al.]. p. cm. “TR-407.” ISBN-13: 978-0-8330-3992-7 (pbk. : alk. paper) 1. Hospitals—Safety measures. 2. Medical errors—Prevention. 3. Medical care—Quality control. I. Teleki, Stephanie. II. Rand Corporation. [DNLM: 1. Patient Safety Improvement Corps (U.S.) 2. Education, Continuing—United States. 3. Health Occupations—education—United States. 4. Government Programs—United States. 5. Medical Errors— prevention & control—United States. 6. Safety Management—United States. W 18 E8965 2006] RA969.9.E93 2006 362.1068'4—dc22 2006021712 A profile of RAND Health, abstracts of its publications, and ordering information can be found on the RAND Health home page at www.rand.org/health. The research described in this report was carried out in RAND Health, a division of the RAND Corporation. This work was sponsored by the Agency for Healthcare Research and Quality. iii Preface Since 2000, the Agency for Healthcare Research and Quality (AHRQ) has had a congressional mandate to take a leadership role in helping health care providers reduce medical errors and improve patient safety. As part of its patient safety initiative, AHRQ established the Patient Safety Improvement Corps (PSIC) in partnership with the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS), which is known for its patient safety expertise. The goal of the PSIC is to improve patient safety across the nation by training health care professionals in core patient safety knowledge, skills, and tools. The core content of the curriculum was developed by AHRQ based upon the findings of a feasibility study as well as consultation with experts and key stakeholders. Through an interagency agreement, AHRQ contracted with the VA NCPS to conduct the training. In September 2002, AHRQ contracted with the RAND Corporation to serve as the Patient Safety Evaluation Center. Under a four-year contract, the evaluation center is responsible for performing a longitudinal, formative evaluation of the full scope of AHRQ’s patient safety activities and for providing regular feedback to support the continuing improvement of the initiative over the evaluation period. In its evaluation, RAND has tracked the patient safety research funded by AHRQ, assessed AHRQ’s activities to translate that research into action, and evaluated the impact of these efforts. Each year, RAND has produced an annual evaluation report that provides an update on the evolution and current status of the priorities and activities being undertaken as part of the AHRQ patient safety initiative. Additionally, RAND has produced separate, in-depth reports on specific evaluation topics. This document is one such stand-alone report. Given the central role of the PSIC in the AHRQ patient safety initiative, a focused assessment of the PSIC has been an important part of the overall patient safety evaluation. This report presents the initial results of RAND’s evaluation of the PSIC. Perceptions and experiences are documented for the first two groups of trainees who have completed the PSIC training. For the first group, information was gathered at the end of their training in May 2004, as well as one year later, after they had time to apply what they had learned. For the second group, information was gathered at the end of their training in May 2005. Updated PSIC evaluation results that draw upon data collected in 2006 will be presented in RAND’s fourth annual evaluation report. This report is intended primarily for use by AHRQ and the VA, to help inform future programming decisions. It also will be of interest to national and state policymakers, health care organizations and clinical practitioners, patient-advocacy organizations, health researchers, and others with responsibilities for ensuring that patients are not harmed by the health care they receive. This work was sponsored by the Agency for Healthcare Research and Quality under Contract No. 290-02-0010, for which James B. Battles serves as project officer. The research was conducted in RAND Health, a division of the RAND Corporation. A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health. v Contents Preface iii Figures vii Tables ix Glossary xi Executive Summary xv Acknowledgments xxvii Chapter 1 Introduction 1 Background 1 The Training Program Design 1 Evaluating the PSIC Role in the AHRQ Patient Safety Initiative 4 Contents of This Report 5 Chapter 2 Lessons from the First-Year PSIC Trainees 7 Overview of Findings 7 Findings from the May 2004 Team Interviews 8 Feedback on the PSIC Experience One Year Later 17 Impact on Patient Safety Actions in the Year Following Training 30 Continuation of Contacts After the End of Training 34 Helpfulness of PSIC Training and Advice to Others 36 Future Training Activities 39 Chapter 3 Second-Year 20042005 Trainees 43 Overview of Findings 43 Findings from the May 2005 Team Interviews 44 Content of the Second-Year PSIC Training 47 Skills and Projects Developed by the Trainees 50 Use of the PSIC Training by the Second-Year Trainees 52 Suggestions from Trainees for Future Program 57 Chapter 4 Conclusions and Recommendations 59 Suggestions for Action by AHRQ 60 Suggestions for Future Program Design 61 Appendix A First Year 2003–2004 Team Interview Protocol 65 Appendix B First Year 2003–2004 Follow-up Telephone Interview Protocol 69 vi Appendix C Second Year 2004–2005 Team Interview Protocol 81 References 87 vii Figures Figure S.1 Assessment by First-Year Trainees of the Helpfulness of PSIC Training in Improving Processes to Monitor and Improve Patient Safety xxiv [...]... these two methods in their projects, the topics of which were selected by the participants (In Year 2, trainees were encouraged to tackle any patient safety project topic of their choice with the expectation that one of the tools or methods provided in their training would be used to complete the projects.) The networking aspects of the course were also valued highly The majority of trainees took the. .. implementing patient safety improvements xxvi Acknowledgments We gratefully acknowledge the participation of numerous people in the evaluation of the Patient Safety Improvement Corps The individuals who were PSIC trainees willingly have provided their time to participate in individual interviews and focus groups, providing valuable information and insights about the PSIC and their use of the training they... and disseminating the most effective practices for use in the U.S health care system The AHRQ patient safety work is one of numerous and important patient safety initiatives being undertaken by a variety of organizations across the country The Patient Safety Improvement Corps (PSIC) is a nationwide training program being carried out as part of AHRQ’s overall patient safety initiative The PSIC was designed... via the conference calls When the third training year is completed and teams from all U.S states and the District of Columbia have been trained, AHRQ plans to shift the PSIC to a train -the- trainer model through which it will teach teams how to train others within their state about patient safety skills and 3 tools The goal of the train -the- trainer portion of the PSIC is to broaden the reach of the. .. EVALUATING THE PSIC ROLE IN THE AHRQ PATIENT SAFETY INITIATIVE AHRQ contracted with RAND in September 2002 to serve as the evaluation center for its national patient safety initiative The evaluation center is responsible for performing a longitudinal evaluation of the full scope of AHRQ’s patient safety activities and for providing regular feedback to support the continuing improvement of this initiative... 2004-2005 The PSIC training focuses on the practical application of patient safety science and techniques Each session builds on what was taught during the previous one In addition, each state team carries out a patient safety project, the results of which are presented at the third training session in May The following are examples of topics covered during the course of the one-year training: overview of patient. .. summarize the findings of the individual interviews conducted with the Year 1 PSIC trainees one year after they completed their training We asked them to consider in hindsight the value of their experience and to identify how they had put their training to work during the past year For many of the topics, we report separately the feedback by the state and hospital participants, recognizing their distinct,... identifying and disseminating the most effective practices for use in the U.S health care system The AHRQ patient safety work is one of numerous and important patient safety initiatives being undertaken by a variety of organizations across the country The Patient Safety Improvement Corps (PSIC) is a nationwide training program being carried out as part of AHRQ’s overall patient safety initiative It is funded... perceptions of the program at the time they were finishing their training Responses from the trainee teams participating in the first and second PSIC rounds are reported separately, to provide comparisons of the experiences of the two groups In the discussion, we refer to the two groups as “Year 1” and “Year 2” trainees or participants We also report separately the perceptions and uses of the program by the. .. participants and their employers Most of the instructors are staff from the NCPS, but the PSIC partners also draw upon outside expertise at AHRQ or in the private sector for some aspects of the program content (e.g., probabilistic risk assessment, just culture, evaluation methods, patient safety indicators, mistake proofing, leading change, patient safety culture, designing for safety) The VA conducts the training, . order@rand.org Library of Congress Cataloging-in-Publication Data Evaluation of the Patient Safety Improvement Corps : experiences of the first two groups of trainees. improve patient safety. As part of its patient safety initiative, AHRQ established the Patient Safety Improvement Corps (PSIC) in partnership with the Department